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Identify the considerations academic surgeons use when determining which portions of a procedure are "critical" and necessitate their presence.Teaching physicians are required to be present for the "critical portion" of surgical procedures, but the definition of what constitutes a critical portion remains elusive. Current guidelines defer to surgeons' expert judgment in identifying critical portion(s) of a procedure; little is known about what concepts surgeons apply when deciding what parts of a procedure are critical.Qualitative analysis of interviews with 51 practicing surgeons from a range of specialties regarding their working definition of critical portions.Surgeons identified 4 common themes that they use in practice to define the critical portions of procedures: portions that require their first-hand observation of events, those involving challenging anatomy or structures that cannot be repaired if injured, and portions where an error would result in severe consequences for the patient. Surgeons also recognized contextual factors regarding the patient, trainee, surgeon, and team that might alter determinations for individual cases.Although critical portion definitions are largely treated as subjective, surgeons across multiple specialties identified consistent themes defining "critical portions'', suggesting that setting a minimum standard for criticality is feasible for specific procedures. Surgeons also recognized contextual factors that support the need for case-specific judgement beyond minimum standard. This framework of procedure features and contextual factors may be used as a guide for surgeons making day-to-day decisions and in future work to formally define critical portions for a given procedure.

During surgical cases, technical errors or unexpected findings can result in a legitimate need for additional surgical expertise and may motivate the primary surgeon to “call for help,” that is, to seek assistance either from colleagues or from additional types of surgical specialists. The intraoperative consultation, initiated by a surgeon’s “call for help,” inserts an additional consulting surgeon into a doctor-patient relationship that had been established before anesthesia between the patient and primary surgeon and places new ethical, legal, and professional duties on the participants. Although we believe these intraoperative consultations occur regularly at most surgical programs, we have few data on how frequently this occurs, who calls whom, what surgical issues prompt such a call, or the outcomes of such consultations. Further, this topic is not addressed by the major codes of ethics and professional conduct. 1,2 The purpose of this article is to open a discussion of the topic of “call for help,” and to propose and outline the duties of the primary and consultant surgeons in this setting. Consider the following scenario: A surgeon takes a 48-year-old woman to the operating room to remove a large goiter. During a difficult dissection, the recurrent laryngeal nerve is injured. The surgeon calls a colleague with expertise in laryngology for an intraoperative consultation, and the colleague scrubs in to evaluate the nerve injury. The surgeons discuss the events that led to the injury and possible courses of action. The primary surgeon had informed the patient of the unlikely possibility of nerve injury and believes that the patient would agree to whatever course of action was medically indicated. The consulting surgeon recommends nerve reanastamosis and vocal cord injection, and the primary surgeon agrees. When the procedure is complete and the patient is awake, the primary surgeon explains the injury and introduces the consulting surgeon to the patient so the consulting surgeon can discuss further care specific to her vocal cords. This scenario describing the “call for help” and resulting intraoperative consultation raises 3 critical questions. First, what are the duties of the primary surgeon to the patient and to the consultant? Second, what obligations does the consulting surgeon accept when agreeing to the consultation? Third, can the consulting surgeon override the primary surgeon(s) if there is disagreement on the next steps of intraoperative management? Definition of intraoperative consultation “Call for help” consultations occur after the patient is anesthetized and can no longer participate in the decision to consult. During the surgery, the patient is not aware that such a consultation has happened. The reason for such consultations are varied: there may be an unexpected anatomic or disease finding; an error or complication; the need for an additional technical procedure that may or may not have been discussed with the patient preoperatively; or an unanticipated challenging case that requires additional surgical expertise. The consultant surgeon may sometimes observe the situation and provide only knowledge or guidance. Often, the consulting surgeon will scrub in to participate in the operation. The primary surgeon may continue operating, or he or she may assume the role of co-surgeon alongside the consulting surgeon, or the primary surgeon may turn over the case entirely to the consulting surgeon if the type of procedure needed is far outside the original surgeon’s area of expertise. In the latter scenario, the primary surgeon becomes an observer or “bystander.” There are other scenarios in which multiple surgeons and/or surgeons not known to the patient participate in the patient’s care in the operating room. Those other situations include “team surgery,” surgical training of residents, and “ghost surgery.” We distinguish the “call-forhelp” from these other 3 scenarios. In the “call-for-help” cases, in which intraoperative consultation is necessary

Background Family members are important in the perioperative care of surgical patients. During the perioperative period, communication about the patient occurs between surgeons and family members. To date, however, surgeon-family perioperative communication remains unexplored in the literature. Study Design Surgeons were recruited from the surgical faculty of an academic hospital to participate in an interview regarding their approach to speaking with family members during and immediately after an operative procedure. An iterative process of transcription and theme development among 3 researchers was used to compile a well-defined set of qualitative themes. Results Thirteen surgeons were interviewed and described what informs their communication, how they practice surgeon-family perioperative communication, and how the skills integral to perioperative communication are taught. Surgeons saw perioperative communication with family members as having a special role of providing support and anxiety alleviation that is distinct from the role of communication during clinic or postoperative visits. Wide variability exists in how interviewed surgeons practice perioperative communication, including who communicates with the family, and the frequency and content of the communication. Surgeons universally reported that residents' instruction in perioperative communication with families was lacking. Conclusions Surgeons recognize perioperative communication with family members to be a part of their role and responsibility to the patient. However, during the perioperative period, they also acknowledge an independent responsibility to alleviate family members' anxieties. This independent responsibility supports the existence of a distinct "surgeon-family relationship."

Introduction Residents learn technical and communication skills during training and practice both concurrently during awake surgical procedures. Patients have expressed mixed views on resident involvement in their surgical care, making this context challenging for residents to navigate. We sought to qualitatively explore resident perspectives on teaching during awake surgical procedures. Methods Residents in Urology, Obstetrics and Gynecology, and General Surgery who had been exposed to 10 or more awake surgical procedures were recruited for recorded focus groups at the University of Chicago. Recordings were transcribed, coded, and reviewed by 3 researchers using the constant comparative method until thematic saturation was reached. Results Twenty-five residents participated in 5 focus groups. Residents identified positive educational techniques during awake surgery including preprocedural communication, explaining teaching and the resident role, whispering/nonverbal communication, involving the patient in education, and confident educator. Residents described challenges and failures in education, including hesitating to ask questions, hesitating to correct a learner, whispering/nonverbal communication, and taking over. In discussing informed consent during awake procedures, some residents described that the consent process should or did change during awake procedures, for example, to include more information about the resident role. Conclusions Residents participating in awake surgical procedures offer new insights on successful techniques for teaching during awake surgery, emphasizing that good communication in the procedure room starts beforehand. They also identify challenges with teaching in this context, often related to a lack of open and clear communication.

In order to develop immunotherapies for prostate cancer, many groups are exploring vaccination strategies to induce an immune response against prostate specific antigen (PSA). To determine if T-cell recognition of PSA might be a feature of a naturally occurring human disease, we have studied patients with prostatitis, a poorly understood clinical syndrome of men in which there is evidence that an immune response directed against the prostate may be occurring. We wished to determine if a T-cell response to PSA might be occurring in these patients. We generated long-term T-cell lines from peripheral blood mononuclear cells (PBMC) of one patient with granulomatous prostatitis using purified PSA as an antigen. Several CD4+ and CD8+ TcR alpha/beta+ T-cell lines were selected for PSA reactivity as measured by at least a threefold increase in IFN-gamma secretion in response to PSA presented by irradiated autologous PBMC. CD4 and CD8 T-cell lines recognized PSA in the context of HLA-DRbeta1*1501 and HLA-B*0702, respectively. The specificity and HLA restriction of the lines was confirmed using EBV-B cell lines infected with a recombinant PSA-expressing vaccinia virus and also engineered to express PSA by retroviral transfection. HLA-matched targets infected by control vector as well as HLA-mismatched PSA-expressing targets did not induce the response. The data demonstrate that PSA-specific T cells are present in the PBMC of this patient with granulomatous prostatitis, who may be manifesting naturally the type of immune response directed at the prostate that is the goal of prostate cancer immunotherapy. However, the Class I-restricted epitope has not yet been demonstrated to be expressed on the surface of prostate cancer cells. To our knowledge, this is the first demonstration of HLA-DRB1*1501- or HLA-B*0702-restricted responses to PSA and extends the number of HLA molecules accommodating the use of PSA antigen as a candidate vaccine for prostate cancer immunotherapy.

The physician-patient relationship is an essential part of end-of-life planning, including discussions of advance directives (AD). Physicians likely to encounter AD issues with their patients were identified and queried as to their knowledge, opinion, and experience with ADs. Though most physicians felt ADs were helpful to both physicians and patients, considerably less were familiar with hospital policies and the different types of ADs. Formal education in the use and function of ADs also appears to be lacking, suggesting a need to improve the way in which ADs are addressed during medical training.